Hemosiderosis of lower cranial nerves: A pitfall in difficult-to-wean tracheotomized patients - A case report

Cerebral hemosiderosis is a condition resulting from recurrent or extensive intracranial hemorrhages, leading to hemosiderin deposition in central nervous system structures and affecting cranial nerves. The classic clinical triad includes sensorineural hearing loss, cerebellar ataxia, and pyramidal signs, with less frequent involvement of other cranial nerves. In our case however, we report a unique presentation of multiple lower cranial nerve involvement following a right-myelencephalic subarachnoid hemorrhage secondary to hemorrhagic ventricular effraction in a 58-year-old male patient. We aim to highlight the implications of atypical cranial nerve hemosiderosis on swallowing and tracheotomy weaning and demonstrate the importance of tailored rehabilitation approaches. The patient presented a coma after hemorrhagic stroke and was later diagnosed with hemosiderosis affecting cranial nerves IX, X, and XII, leading to severe dysphagia and delayed tracheotomy weaning. Magnetic resonance imaging with susceptibility-weighted sequence confirmed the diagnosis. Neurorehabilitation was adjusted to incorporate specific swallowing techniques addressing pharyngeal motor deficits. Despite the tracheotomy weaning delay (31 vs 12.75 days average), a specific adaptation of cervical posture during the swallowing, that is, anterior flexion combined with a rotation ipsilateral to the affected side helped to secure swallowing and promote tracheotomy weaning. This case emphasizes that hemosiderin deposits can affect cranial nerves beyond the typical vestibulocochlear nerve, possibly influenced by cerebrospinal fluid flow patterns near Magendie's foramen. This case underscores the need for early diagnosis and tailored rehabilitation in cerebral hemosiderosis with atypical cranial nerve involvement to optimize functional outcomes. Further research is essential to guide management in such rare presentations.